The Four Square Step Test (FSST) is a clinical test of dynamic balance. It tests the ability to step over objects in forward, sideways, and backward directions as quickly as the participant is able to do so.1 It has been tested for different populations and compared with other tests assessing balance and mobility. 1-5
Objectives:
Learn how the FSST is performed.
Learn about what populations the FSST may be used for.
Learn how the FSST is scored and what the scores mean.
Discuss the advantages and disadvantages of clinical use.
How the FSST is performed:
Equipment needed – stopwatch and four canes Set up – Place the canes on the ground to create four squares (illustrated below)
Instructions – Describe the step sequence to the participant. Start in square 1 and follow the following step sequence: 2, 3, 4, 1, 4, 3, 2, 1. Demonstrate the step sequence to the participant .Tell the participant, “Try to complete the sequence as fast as possible without touching the stick. Both feet must make contact with the floor in each square. If possible, face forward during the entire sequence.”
Perform the test – The participant is allowed one practice test. The best of two trials is scored. A trial is repeated is the participant fails to complete the sequence, loses balance, or makes contact with the canes.
The FSST has been found to be useful for the following populations: Older adults/geriatrics, vestibular dysfunction, transtibial amputations, acute stroke, and parkinson’s disease.1-5
How the test is scored and what the scores mean:
The time is takes the participant to complete the sequence is timed using the stopwatch. The time starts once the first foot touches down in square 2 and ends when the 2nd foot touches down back in square 1. Cutoff times have been established for identifying the risk for falls in the following populations.
Older Adults/Geriatrics: > 15s = at risk for multiple falls1 Vestibular: > 12s = at risk for falls5 Transtibial Amputation: > 24s = at risk for falls3 Acute Stroke: failed attempt or > 15s = increased risk for falls2 Parkinson’s Disease: > 9.68s = increased risk for falls4
Advantages and Disadvantages in clinical use:
Advantages of the FSST are that it is easy to score, takes a short time (5min), requires little space and no specialized equipment, and it allows the participant to use an assistive device if they are currently using one. It also useful in assessing a more complex aspect of balance due to the multidirectional and quick stepping sequence, and it provides a cognitive challenge in remembering the sequence.1 Studies have also reported that it is preferred by participants because it is relevant to daily life and examined challenging skills.2
Some disadvantages of the FSST are that it requires increased attention and physical presence from the tester. It may not be useful for those with cognitive issues due to the task of remembering the stepping sequence. There is also an issue with scoring in that a score cannot be given if the participant is unable to complete the sequence.1
Sources:
1) Dite W. , Temple V.A. A clinical test of stepping and change of direction to identify multiple falling older adults. Arch Phys Med Rehabil. 2002; 83(11): 1566-1571. 2) Blennerhassett J.M., Jayalath v.M. The four square step test is a feasible and valid clinical test of dynamic standing balance for use in the ambulant people poststroke. Arch Phys Med Rehabil. 2008; 89(11): 2156-2161 3) Dite W., Connor H.J., et al. Clinical identification of multiple fall risk early after transtibial amputation. Arch Phys Med Rehabil. 2007; 88(1): 109-114 4) Duncan R.P., Earhart G.M. Four square step test performance in people with Parkinson disease. Journal of Neurologic Physical Therapy. 2013; 37(1): 2-8. 5) Whitney S.L., Marchetti G. F., et al. The reliability and validity for the four square step test for people with balance deficits secondary to a vestibular disorder. Arch Phys Med Rehabil. 2007; 88(1): 99-104. 6) Rehab Measures: Four Square Step Test. http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=900
Published October 30, 2010. Updated November 19, 2014. Accessed June 6, 2016.
The Four Square Step Test (FSST) is a clinical test of dynamic balance. It tests the ability to step over objects in forward, sideways, and backward directions as quickly as the participant is able to do so.1 It has been tested for different populations and compared with other tests assessing balance and mobility. 1-5
Objectives:
How the FSST is performed:
Equipment needed – stopwatch and four canes
Set up – Place the canes on the ground to create four squares (illustrated below)
Instructions – Describe the step sequence to the participant. Start in square 1 and follow the following step sequence: 2, 3, 4, 1, 4, 3, 2, 1. Demonstrate the step sequence to the participant .Tell the participant, “Try to complete the sequence as fast as possible without touching the stick. Both feet must make contact with the floor in each square. If possible, face forward during the entire sequence.”
Perform the test – The participant is allowed one practice test. The best of two trials is scored. A trial is repeated is the participant fails to complete the sequence, loses balance, or makes contact with the canes.
-A more complete description of the test can be found on the Rehab Measures website: http://www.rehabmeasures.org/PDF%20Library/Four%20Step%20Square%20Test%20Instructions.pdf
Populations the FSST can be used for:
The FSST has been found to be useful for the following populations: Older adults/geriatrics, vestibular dysfunction, transtibial amputations, acute stroke, and parkinson’s disease.1-5
How the test is scored and what the scores mean:
The time is takes the participant to complete the sequence is timed using the stopwatch. The time starts once the first foot touches down in square 2 and ends when the 2nd foot touches down back in square 1. Cutoff times have been established for identifying the risk for falls in the following populations.
Older Adults/Geriatrics: > 15s = at risk for multiple falls1
Vestibular: > 12s = at risk for falls5
Transtibial Amputation: > 24s = at risk for falls3
Acute Stroke: failed attempt or > 15s = increased risk for falls2
Parkinson’s Disease: > 9.68s = increased risk for falls4
Advantages and Disadvantages in clinical use:
Advantages of the FSST are that it is easy to score, takes a short time (5min), requires little space and no specialized equipment, and it allows the participant to use an assistive device if they are currently using one. It also useful in assessing a more complex aspect of balance due to the multidirectional and quick stepping sequence, and it provides a cognitive challenge in remembering the sequence.1 Studies have also reported that it is preferred by participants because it is relevant to daily life and examined challenging skills.2
Some disadvantages of the FSST are that it requires increased attention and physical presence from the tester. It may not be useful for those with cognitive issues due to the task of remembering the stepping sequence. There is also an issue with scoring in that a score cannot be given if the participant is unable to complete the sequence.1
Sources:
1) Dite W. , Temple V.A. A clinical test of stepping and change of direction to identify multiple falling older adults. Arch Phys Med Rehabil. 2002; 83(11): 1566-1571.
2) Blennerhassett J.M., Jayalath v.M. The four square step test is a feasible and valid clinical test of dynamic standing balance for use in the ambulant people poststroke. Arch Phys Med Rehabil. 2008; 89(11): 2156-2161
3) Dite W., Connor H.J., et al. Clinical identification of multiple fall risk early after transtibial amputation. Arch Phys Med Rehabil. 2007; 88(1): 109-114
4) Duncan R.P., Earhart G.M. Four square step test performance in people with Parkinson disease. Journal of Neurologic Physical Therapy. 2013; 37(1): 2-8.
5) Whitney S.L., Marchetti G. F., et al. The reliability and validity for the four square step test for people with balance deficits secondary to a vestibular disorder. Arch Phys Med Rehabil. 2007; 88(1): 99-104.
6) Rehab Measures: Four Square Step Test.
http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=900
Published October 30, 2010. Updated November 19, 2014. Accessed June 6, 2016.